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Original Articles

Cost-Effectiveness of Percutaneous Coronary Intervention in Optimally Treated Stable Coronary Patients

William S. Weintraub, MD; William E. Boden, MD; Zugui Zhang, PhD; Paul Kolm, PhD; Zefeng Zhang, MD, PhD; John A. Spertus, MD, MPH; Pamela Hartigan, PhD; Emir Veledar, PhD; Claudine Jurkovitz, MD, MPH; Jim Bowen; David J. Maron, MD; Robert O'Rourke, MD; Marcin Dada, MD; Koon K. Teo, MD; Ron Goeree, MS; Paul G. Barnett, PhD on Behalf of the Department of Veterans Affairs Cooperative Studies Program No. 424 (COURAGE Trial) Investigators and Study Coordinators^*

From Christiana Care Health System (W.S.W., Zugui Zhang, P.K., C.J., J.B.), Newark, Del; Western New York Veterans Affairs Healthcare Network and Kaleida Health System (W.E.B.), Buffalo, NY; Emory University (Zefeng Zhang, E.V.), Atlanta, Ga; Mid-America Heart Institute/University of Missouri—Kansas City (J.A.S.), Kansas City, Mo; Cooperative Studies Program Coordinating Center (P.H.), VA Connecticut Healthcare System, West Haven, Conn; Vanderbilt University Medical Center (D.J.M.), Nashville, Tenn; San Antonio Veterans Affairs Medical Center (R.O.), San Antonio, Tex; Hartford Hospital (M.D.), Hartford, Conn; McMaster University (K.K.T., R.G.), Hamilton, Ontario, Canada; and Veterans Affairs Health Economics Resource Center (P.G.B.), Palo Alto, Calif.

Correspondence to William S. Weintraub, MD, John H. Ammon Chair and Director, Cardiology Section, Christiana Care Health System, 4755 Ogletown-Stanton Rd, Newark, DE 19718. E-mail wweintraub{at}christianacare.org

Received June 11, 2008; accepted July 10, 2008.

Background— The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive druG Evaluations) trial compared the effect of percutaneous coronary intervention (PCI) plus optimal medical therapy with optimal medical therapy alone on cardiovascular events in 2287 patients with stable coronary disease. After 4.6 years, there was no difference in the primary end point of death or myocardial infarction, although PCI improved quality of life. The present study evaluated the relative cost and cost-effectiveness of PCI in the COURAGE trial.

Methods and Results— Resource use was assessed by diagnosis-related group for hospitalizations and by current procedural terminology code for outpatient visits and tests and then converted to costs by use of 2004 Medicare payments. Medication costs were assessed with the Red Book average wholesale price. Life expectancy beyond the trial was estimated from Framingham survival data. Utilities were assessed by the standard gamble method. The incremental cost-effectiveness ratio was expressed as cost per life-year and cost per quality-adjusted life-year gained. The added cost of PCI was approximately $10 000, without significant gain in life-years or quality-adjusted life-years. The incremental cost-effectiveness ratio varied from just over $168 000 to just under $300 000 per life-year or quality-adjusted life-year gained with PCI. A large minority of the distributions found that medical therapy alone offered better outcome at lower cost. The costs per patient for a significant improvement in angina frequency, physical limitation, and quality of life were $154 580, $112 876, and $124 233, respectively.

Conclusions— The COURAGE trial did not find the addition of PCI to optimal medical therapy to be a cost-effective initial management strategy for symptomatic, chronic coronary artery disease.

Key Words: coronary disease • angina • epidemiology • cost-benefit analysis • stents

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CLINICAL PERSPECTIVE

*Members of the COURAGE Study Group are listed in reference ⁶.

Guest Editor for this article was Eric D. Peterson, MD.

Clinical trial registration information—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00007657.

The online-only Data Supplement is available with this article at http://circoutcomes.ahajournals.org/cgi/content/full/1/1/12/DC1.

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